INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA, HYDERABAD
APPLICATION FOR RECRUITMENT TO THE POST OF ASSISTANT MANAGER
PART I
Post applied for______
Specialization applied for ______
(A)Personal details
S. No / Details1 / Name (In Block Letters)
2 / Father’s name
3 / Nationality
4 / Religion to which you belong to
5 / Date of Birth/Age
6 / Mother Tongue
7 / Present Residential Address with Pin code
8 / Permanent Residential Address Pin code
9 / Sex (Male/Female)
10 / Marital status (Single/Married/Divorced)
11 / Telephone No. / Mobile No.
12 / E-mail id
13 / Whether belongs to SC/ST Category?
14 / (i)Whether belongs to OBC category?
(ii)If yes, whether belongs to “Creamy layer”? / (i)
(ii)
15 / (i) Whether belongs to PWD (Persons with Disability) category?
(ii) If yes, mention the % of disability / (i)
(ii)
16 / (i) Whether belongs to Ex- Servicemen category?
(ii) If yes, date of discharge from service / (i)
(ii)
17 / (i)Organization in which working
(ii)Address
(iii)Tel. No. / (i)
(ii)
(iii)
18 / Languages known / Language (Read, Write, Speak)
Mark ‘Y’ or ‘N’ / R / W / S
1.
2.
3.
(B) Qualifications
1. Academic Qualifications (Graduation onwards):
Examinationpassed / University/ Institute /Board / Year of Passing / Duration of Course / Subjects / Percentage of Marks/CGPA/Division
2. Professional qualifications:
Examinationpassed / University/ Institute /Board / Year of Passing / Duration of Course / Subjects / Percentage of Marks/CGPA/Division
(C) Service details
(i) Details of present employment held:
Sl. No / Details1 / (i) Post held
(ii) Designation / (i)
(ii)
2 / (i) Total no. of years of service
(ii) No. of years in the present post / (i)
(ii)
3 / Present Pay scale
4 / Present Basic pay, Grade pay/Grade Allowance, if any (Pl. attach pay slip)
5 / Experience in different areas/fields of working:
Department / Job profile / No. of years
1.
2.
3.
4.
(ii) Details of previous employment:
Office/Institute/Organization / Post/Designation held / Period / Natureof
Appointment and job profile / Scale of Pay
and
Basic
pay & Grade Pay/Gr. Allowance, if any / Gross salary and Net salary
From / To
(iii) Have you ever been on deputation during your service to any organization including IRDAI?
Office/Organization / Post Held
On deputation / Period / Scale of Pay
and
Basic pay / Pay Band & Grade Pay / Nature of duties
Date of deputation / Date of repatriation
(iv) For IRDAI staff applicants:
Sl. No / Details1 / Date of joining IRDAI
2 / Details of service in IRDAI
Designation / From / To / Department
(i)
(ii)
(D) Training
Have you in the past attended any specialized trainingprogramme?
Sl. No / Name of the Institute / Period of Training / Details of Trainingcourse undergone1
2
(E) Other information
Sl. No / Details1 / How do you consider yourlevel of proficiency in Insurance/Financial services?
Specify in terms of Average or Advanced
2 / How do you consider yourlevel of proficiency in computer skills?
Specify in terms of Average or Advanced.
3 / Has any Vigilance case been instituted against you?
Pl. furnish details (including those cases disposed off)
4 / Any other relevant information, which you wish to furnish
(F) Suitability
Please state briefly how you find yourself best suitable for the post applied for(G) References (of Officers holding position 2 steps above the cadre of the applicant)
Sl. No / Name / Designation / Address / Contact Nos.1.
2.
DECLARATION
- I hereby declare that the all the statements made in this application are true, complete and correct to the best of my knowledge and belief.
- I declare that
a)I have not been, at any time, convicted by a court in India for any offence involving moral turpitude.
b)No proceedings in respect of an offence alleged to have been committed by me are pending before a criminal court in India.
c)No warrant or summons for the appearance, or a warrant for arresting mehas been issued by a court under any law for the time being in force or that an order prohibiting me from departure from India has been issued by any such court.
2. I understand that any incorrect information furnished by me is found to be false or that does not satisfy the eligibility criteria will lead to my disqualification from the selection process and my candidature/appointment is liable to be cancelled / terminated.
3. I agree and declare that my admission to the written examination/interview is strictly provisional. The mere fact that the call letter for written examination/interview has been issued to me does not imply that my candidature has been finally cleared by IRDAI and further it does not entitle me for appointment in IRDAI unless an appointment letter is issued to me.
4. I understand and agree that in case of any selection process violation by me, I will not be allowed to appear in any IRDAI recruitment process in the future. Further, I understand and agree that if such instances go undetected during the current selection process but are detected subsequently, such disqualification will take place with retrospective effect.
Date:(Signature of the Applicant)
Place:
Encl: Self attested copies of all certificates pertaining to the following are enclosed:
(i)Date of birth
(ii)Educational qualifications
(iii)Marks sheets (from Graduation onwards)
(iv)Professional qualifications
(v)Caste certificate, Disability certificate etc.(where applicable)
Part II
Certificationfrom Organization where the applicant is presently working
- The service particulars given by the applicant are verified with reference to his
- (a) There are no vigilance/non vigilance/Miscellaneous cases pending against the applicant in the records maintained by us.
(b) Details of vigilance/Miscellaneous cases filed against the applicant and disposed off in the past: ______
______
______
(Pl. tick the appropriate columnand furnish information where necessary)
- Terms of relief, if the applicant is selected for appointment in IRDAI - ______.
Date:(Signature of the Competent Authority)
Place: (Office seal)
PROFORMA – I
DISABILITY CERTIFICATE
NAME & ADDRESS OF THE INSTITUTE/HOSPITAL
Certificate No______Date:
This is certified that Shri/Smt./Kum...... son/wife/daughter of Shri...... age ...... sex ...... identification mark(s) ...... has appeared before us and we observe that he/sheis suffering from permanent disability of following category:
A. Loco motor or Cerebral Palsy:
(i) BL— Both legs affected but not arms
(ii) BA—Both arms affected (a) Impaired reach
(b) Weakness of grip
(iii) BLA—Both legs and both arms affected
(iv) OL — One leg affected (right or left) (a) Impaired reach
(b) Weakness of grip
(c) Ataxic
(v) OA — One arm affected (a) Impaired reach
(b) Weakness of grip
(c) Ataxic
(vi) BH—Stiff back and hips (cannot sit or stoop)
(vii) MW—Muscular weakness and limited physical endurance.
B. Blindness or Low Vision:
(i) B—Blind
(ii) PB—Partially blind
C. Hearing impairment:
(i) D—Deaf
(ii) PD—Partially deaf
(Delete the category whichever is not applicable)
2. This condition is progressive/non-progressive/likely to improve/not likely to improve. Reassessment of this case is not recommended/is recommended after a period of ...... years ...... months.*
3. Percentage of disability in his/her case is...... Percent.
4. Shri/Smt./Kum...... Meets the following physical requirements for discharge of his/her duties:—
(i) F—Can perform work by manipulating with fingers. Yes/No
(ii) PP—Can perform work by pulling and pushing. Yes/No
(iii) L—Can perform work by lifting. Yes/No
(iv) KC—Can perform work by kneeling and crouching. Yes/No
(v) B—Can perform work by bending. Yes/No
(vi) S—Can perform work by sitting. Yes/No
(vii)ST—Can perform work by standing. Yes/No
(viii)W—Can perform work by walking. Yes/No
(ix) SE—Can perform work by seeing. Yes/No
(x) H—Can perform work by hearing/speaking. Yes/No
(xi) RW—Can perform work by reading and writing. Yes/No
(Dr...... ) (Dr...... ) (Dr...... )
Member Member Chairman
Medical Board Medical Board Medical Board
Countersigned by the Medical Superintendent/CMO/Head of Hospital (With seal)
PROFORMA - II
FORM OF CERTIFICATE TO BE PRODUCED BYOTHER BACKWARD CLASSES
This is to certify that Shri/Smt./Kumari/______son/daughter of______of Village/town______in District/Division______in the State/Union Territory ______belongs to the ______community which is recognized as a backward class under the Government of India, Ministry of Social Justice and Empowerment’s Resolution No. ______dated ______*. Shri/Smt./Kumari______and/or his/her family ordinary reside(s) in the ______District/Division of the______State/Union Territory. This is also to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in column 3 of the Schedule to the Government of India, Department of Personnel & Training O.M. No.36012/22/93-Estt(SCT) dated 8.09.1993**.
District Magistrate,
Deputy Commissioner, etc.
Dated
Seal
* The authority issuing the certificate may have to mention the details of Resolution of Government of India, in which the caste of the candidate is mentioned as OBC.
** As amended from time to time.
Note:- The term “ordinarily” used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.
Note: Caste validity certificate in original, from the appropriate authorities of the state/union territory from which the caste certificate was issued along with self-attested Photostat copy is to be submitted at the time of interview.
Form of undertaking to be submitted by the OBC candidate
(in addition to the Community Certificate)
UNDERTAKING
I, ….…………………………….. Son/daughter of Shri …………………. Resident of …………………………..village/town/city………………….district……………………….… State/UT ……………… hereby declare that I belong to the………………..community which is recognized as a backward class by the Government of India for the purpose of reservation in services as per orders contained in Department of Personnel and Training Office Memorandum No. 36012/22/93-Estt.(SCT) dated 08.09.1993. It is also declared that I do not belong to Persons/sections (Creamy Layer) mentioned in column 3 of the Schedule to the above referred Office Memorandum dated 08.9.1993, O.M. No. 36033/3/2004-Estt.(Res.) dated 9th March, 2004 and O.M. No. 36033/3/2004-Estt.(Res.) dated 14th October, 2008 and O.M. No.36033/1/2013-Estt.(Res.) dated 27th May, 2013.
Signature of Candidate
Place:
Dated:
PROFORMA - III
FORM OF SCHEDULED CASTE/ TRIBE CERTIFICATE
This is to certify that Shri/Shrimati/Kumari*...... Son/daughter* of ...... Of village/town* ...... in District/Division* ...... of the State/Union Territory* ...... belongs to the...... Caste/Tribe* which is recognized as a Scheduled Caste/Scheduled Tribe* under:—
* The Constitution (Scheduled Castes) Order, 1950
* The Constitution scheduled Tribes) Order, 1950
* The Constitution (Scheduled Castes) Union Territories Order, 1951
* The Constitution (Scheduled Tribes) Union Territories Order, 1951
[as amended by the Scheduled Castes and Scheduled Tribes List (Modification) Order, 1956; the Bombay Reorganization Act, 1960, the Punjab Reorganization Act, 1966, the State of Himachal Pradesh Act, 1970, the North Eastern Areas (Reorganization) Act, 1971, the Scheduled Castes and Scheduled Tribes Order (Amendment) Act, 1976., the State of Mizoram Act, 1986, the State of Arunachal Pradesh Act, 1986 and the Goa, Daman and Diu (Reorganization) Act, 1987.]
* The Constitution (Jammu and Kashmir) Scheduled Castes Order, 1956
* The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959 as amended by the Scheduled Castes and Scheduled Tribes Order (Amendment) Act, 1976 @ The Constitution (Dadar and Nagar Haveli) Scheduled Castes Order, 1962
* The Constitution (Dadar and Nagar Haveli) Scheduled Tribes Order, 1962
* The Constitution (Pondicherry) Scheduled Castes Order, 1964
* The Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967
* The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968
* The Constitution (Goa, Daman and Diu) Scheduled Tribes Order, 1968
* The Constitution (Nagaland) Scheduled Tribes Order, 1970
* The Constitution (Sikkim) Scheduled Castes Order, 1978
2. Shri/Shrimati*/Kumari*______and/or* his/her* family ordinarily reside(s) in Village/town*______of ______District/Division* of the State/Union Territory of ______
Signature______
Designation______
Signature of the Competent Authority@
Place______
Date______
*Please delete the words which are not applicable.
Note: The term “Ordinarily resides” used here will have the same meaning as in Section 20 of the Representation of the Peoples Act, 1950.
@ Authorities who are competent to issue the Scheduled Caste/Tribe certificate are as follows:
District Magistrate / Additional District Magistrate / Collector/Deputy Commissioner/ Deputy Collector/ First Class Stipendiary Magistrate/ Sub-Divisional Magistrate/ Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner (Not below the rank of First Class Stipendiary Magistrate).
Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate/ Revenue Officer not below the rank of Tehsildar.
Sub-Divisional Officer of the area where the candidate and/or his family normally resides.
In so far as the Scheduled Tribes community of Tamil Nadu is concerned, the Certificate given by the Revenue Divisional Officer instead of Tehsildar will only be accepted.
Note: Caste validity certificate in original, from the appropriate authorities of the state/union territory from which the caste certificate was issued along with self-attested Photostat copy is to be submitted at the time of interview.
PROFORMA – IV
CERTIFICATE TO BE PRODUCED BY SERVING/RETIRED/RELEASED ARMED FORCES PERSONNEL FOR AVAILING THE AGE CONCESSION
A. Form of Certificate applicable for Released/Retired Personnel
It is certified that No...... Rank...... Name...... whose date of birth is...... has rendered service from...... to...... in Army/Navy/Air Force.
2. He has been released from military services:
#a) on completion of assignment otherwise than
(i) by way of dismissal, or
(ii) by way of discharge on account of misconduct or inefficiency, or
(iii) on his own request, but without earning his pension, or
(iv) he has not been transferred to the reserve pending such release
#b) on account of physical disability attributable to Military Service.
#c) on invalidment after putting in at least five years of Military service
3. He is covered under the definition of Ex-Serviceman (Re-employment in Central Civil Services and Posts) Rules, 1979 as amended from time to time
Signature, Name and Designation
of the Competent Authority**
SEAL
Place: ......
Date: ......
# Delete the paragraph which is not applicable.
B. Form of Certificate for Serving Personnel
(Applicable for serving personnel who are due to be released within one year)
It is certified that No. ……………Rank……….Name………. is serving in the Army/Navy/Air Force from……………………
2. He is due for release retirement on completion of his specific period of assignment on……………..
#a) on completion of assignment otherwise than
(i) by way of dismissal, or
(ii) by way of discharge on account of misconduct or inefficiency, or
(iii) on his own request, but without earning his pension, or
(iv) he has not been transferred to the reserve pending such release
#b) on account of physical disability attributable to Military Service.
#c) on invalidment after putting in at least five years of Military service
3. No disciplinary case is pending against him.
Signature, Name and Designation
of the Competent Authority**
SEAL
Place: ......
Date: ......
# Delete the paragraph which is not applicable.
**Authorities who are competent to issue certificate to Armed Forces Personnel for availing Age concessions are as follows:
(a)In case of Commissioned Officers including ECOs/SSCOs.
Army - Military Secretary Branch, Army Hqrs., New Delhi
Navy - Directorate of Personnel, Naval Hqrs., New Delhi
Air Force - Directorate of Personnel Officers, Air Hqrs., New Delhi
(b)In case of JCOs/ORs and equivalent of the Navy and Air Force.
Army - By various Regimental Record Offices
Navy - BABS, Mumbai
Air Force - Air Force Records, New Delhi
Candidate (Serving Personnel) furnishing Certificate B as above will have to give the following undertaking:
Undertaking to be given by serving Armed Force personnel who are due to be released within one year
I understand that if selected on the basis of the recruitment/Examination to which this application relates, my appointment will be subject to my producing documentary evidence to the satisfaction of the appointing authority that I have been duly released/retired/discharged from the Armed Forces and that I am entitled to the benefits admissible to Ex-Servicemen in terms of the Ex-Servicemen (Re-employment in Central Civil Service and Posts) Rules, 1979, as amended from time to time.
Place: Signature and Name of Candidate
Date :
FORM OF UNDERTAKING TO BE GIVEN BY CANDIDATES APPLYING
FOR CIVIL POSTS UNDER EX-SERVICEMEN CATEGORY
I understand that if selected on the basis of the recruitment/Examination to which this application relates, my appointment will be subject to my producing documentary evidence to the satisfaction of the appointing authority that I have been duly released/retired/discharged from the Armed Forces and that I am entitled to the benefits admissible to Ex-Servicemen in terms of the Ex-Servicemen (Re-employment in Central Civil Services and Posts) Rules, 1979, as amended from time to time.
2. I also understand that I shall not be eligible to be appointed to a vacancy reserved for Ex-servicemen in regard to the recruitment covered by this examination, if I have at any time prior to such appointment, secured any employment on the civil side (including Public Sector Undertaking, Autonomous Bodies/Statutory Bodies, Nationalized Banks, etc.) by availing of the concession of reservation of vacancies admissible to Ex-servicemen.
Signature of Candidate
Place:
Date:
1